The Shock Index is not accurate at predicting outcomes in patients with upper gastrointestinal bleeding

Defining and Evaluating the Impact of Bleeding Severity on Time to Endoscopy and Mortality Risk: A Prospective Multicenter Cohort Study

Background: Upper gastrointestinal bleeding severity (BleSev) is commonly defined by evaluating different factors that are frequently interdependent on each other, expressing the same underlying cause. Aim: This study aimed to define the severity of a bleeding event and verify its impact on death risk and the time to endoscopy. Methods: We analyzed 12 factors (demographic, hemodynamic, biochemical, and clinical) that could be associated with BleSev. We identified the independent weight of each factor in predicting a composite endpoint (need for surgery, interventional radiology, and death) and the effect of the interactions between time to endoscopy and BleSev on death risk. Results: Clinical data of 2.525 patients were included. Of the 12 factors, 5 were retained in the final model as follows: altered mental status, systolic blood pressure ≤ 100 mmHg, blood urea nitrogen level ≥ 130 mg/dL, hematemesis, and hemoglobin level ≤ 8 g/dL (AUC performance curve, 0.79). We identified the following three classes of BleSev: low (0-1 points, 2.4%), intermediate (3-4 points, 8.6%), and high (≥5 points, 21.1%). When no factors were present, the death risk was 1%; when all factors were present, the risk was 45.5%. Notably, the death risk increased with BleSev but was generally independent of time to endoscopy. However, in high-risk cases, early endoscopy (within 6-12 h) was associated with a reduced mortality rate. Conclusions: This study defines a risk model for BleSev and highlights the need for targeted endoscopic timing strategies based on BleSev for optimizing survival rates. Patients in the highest risk category may benefit from more urgent endoscopic interventions.

The efficacy and comparison of upper gastrointestinal bleeding risk scoring systems on predicting clinical outcomes among emergency unit patients

BACKGROUND

Gastrointestinal bleeding is a significant cause of morbidity and mortality among emergency unit patients. Several scoring systems are verified for predicting hospitalization and mortality such as Glasgow Blatchford Bleeding Score (GBS), AIMS65 score, Rockall score (RS), and International Bleeding Risk Score (INBS; ABC score). The aim of this study is to evaluate the efficacy and predictive value of these scoring systems.

METHODS

Adult emergency unit patients with gastrointestinal bleeding were retrospectively enrolled. The age, gender, complaints at admission, vitals and examination results, laboratory findings, outcomes, blood transfusion status, and endoscopic interventions were all reported, and GBS, AIMS65, RS, and INBS (ABC) scores were calculated individually for all enrollies.

RESULTS

A total of 311 patients were included. The median age of participants was 70 years (IQR (25-75%): 59-81), and 202 (65%) of them were male. The efficacy of all four scoring systems (GBS, AIMS65, RS, and INBS (ABC)) in predicting hospitalization, need of blood transfusion, determination of high- and low-risk patients, and mortality was found to be statistically significant (p < 0.05 for all). ROC-AUC analysis was revealed that while GBS is the most beneficial in predicting hospitalization, INBS (ABC) has the best predictive value on mortality. Besides, the only scoring model with predictive value in determining the need for endoscopic intervention was RS (p < 0.05).

CONCLUSION

The present study showed that, among adult emergency unit patients with gastrointestinal bleeding, GBS, AIMS65, RS, and INBS (ABC) scores could successfully predict hospitalization, need of blood transfusion, determination of high- and low-risk patients, and mortality. However, the only scoring system that could be used to determine the need of endoscopic intervention is RS. Finally, we believe further studies with prospective enrollment would be beneficial for more accurate conclusions.

Efficacy and safety of conservative treatment for colonic diverticular bleeding: Prospective study

Background and study aims

This prospective study aimed to establish the efficacy and safety of conservative treatment for non-severe cases of colonic diverticular bleeding and to verify whether early colonoscopy is necessary only in limited cases.

Patients and methods

Patients who were urgently hospitalized due to hematochezia and were diagnosed with colonic diverticular bleeding were included. During hospitalization, early colonoscopy within 24 hours after admission was performed only when both systolic blood pressure < 90 mm Hg and extravasation on contrast-enhanced computed tomography were observed. However, in patients who failed to recover from hemorrhagic shock, interventional radiology was performed. In other cases, patients received conservative treatment.

Results

Of the 172 patients, 15 (8.7%) met the criteria for undergoing early colonoscopy; 12 and three attained successful hemostasis via early colonoscopy and interventional radiology, respectively. Meanwhile, 157 patients received conservative treatment, resulting in spontaneous hemostasis in 148 patients (94.3%). The remaining nine patients required hemostatic intervention. No patient died from bleeding. Between the conservative treatment and the urgent hemostasis groups, the early rebleeding rate within 30 days (14.6% vs. 33.3%, P = 0.0733) and the overall 1-year cumulative rebleeding rate after 30 days of hospitalization (9.2% vs. 23.1%, P = 0.2271) were not significant. In multivariate analyses, only systolic blood pressure and extravasation were associated with a requirement for hemostatic intervention in 24 patients. Moreover, multivariate analyses showed that a history of diverticular bleeding, undergoing hemodialysis, or use of oral thienopyridine were significantly associated with late rebleeding.

Conclusions

Conservative treatment for non-severe colonic diverticular bleeding is appropriate and efficient.

Variceal and Nonvariceal Upper Gastrointestinal Bleeding Refractory to Endoscopic Management: Indications and Role of Interventional Radiology

For over 60 years, diagnostic and interventional radiology have been heavily involved in the evaluation and treatment of patients presenting with gastrointestinal bleeding. For patients who present with upper GI bleeding and have a contraindication to endoscopy or have an unsuccessful attempt at endoscopy for identifying or controlling the bleeding, interventional radiology is often consulted for evaluation and consideration of catheter-based intervention.

Lactate level as a predictor of outcomes in patients with acute upper gastrointestinal bleeding: A systematic review and meta‑analysis

There remains no consensus on the prognostic value of lactate in predicting adverse outcomes such as mortality, rebleeding and higher intensive care unit (ICU) admission rates in patients with upper gastrointestinal bleeding (UGIB). The present study aimed to determine the prognostic accuracy of lactate level in predicting adverse clinical outcomes in patients with acute UGIB. Systematic literature search was conducted in PubMed Central, SCOPUS, EMBASE, MEDLINE, Google Scholar and ScienceDirect databases for studies published up to February 2023. Random-effects model was used for the meta-analysis and the results were presented as pooled standardized mean differences or odds ratio (OR) with 95% confidence interval (CIs). A total of 11 studies were included in the present review. Most of the studies had a high risk of bias. Pooled OR were as follows: 1.39 (95% CI: 1.29-1.51; I2=85%) for the prediction of mortality; 1.29 (95% CI: 1.17-1.42; I2=85.9%) for prediction of ICU admission, 1.14 (95% CI: 1.06-1.23; I2=42.4%) for rebleeding and 2.84 (95% CI: 2.14-3.77; I2=8.1%) for the need of packed red blood cell (pRBC) transfusion. Sensitivity and specificity for the mortality prediction were 72% (95% CI: 57-83%) and 75% (95% CI: 61-85%), respectively, with the area under the curve of 0.79 (95% CI: 0.72-0.85). In conclusion, the results showed that lactate level is a moderately accurate early prediction marker of most adverse clinical outcomes such as mortality, rebleeding, ICU admission and the need for pRBC transfusion in acute UGIB patients.

A nomogram to predict in-hospital mortality of gastrointestinal bleeding patients in the intensive care unit

Background

Gastrointestinal bleeding (GIB) is a common condition in clinical practice, and predictive models for patients with GIB have been developed. However, assessments of in-hospital mortality due to GIB in the intensive care unit (ICU), especially in critically ill patients, are still lacking. This study was designed to screen out independent predictive factors affecting in-hospital mortality and thus establish a predictive model for clinical use.

Methods

This retrospective study included 1,442 patients with GIB who had been admitted to the ICU. They were selected from the Medical Information Mart for Intensive Care IV (MIMIC-IV) 1.0 database and divided into a training group and a validation group in a ratio of 7:3. The main outcome measure was in-hospital mortality. Least absolute shrinkage and section operator (LASSO) regression was used to screen out independent predictors and create a nomogram.

Results

LASSO regression picked out nine independent predictors: heart rate (HR), activated partial thromboplastin time (aPTT), acute physiology score III (APSIII), sequential organ failure assessment (SOFA), cerebrovascular disease, acute kidney injury (AKI), norepinephrine, vasopressin, and dopamine. Our model proved to have excellent predictive value with regard to in-hospital mortality (the area under the receiver operating characteristic curve was 0.906 and 0.881 in the training and validation groups, respectively), as well as a good outcome on a decision curve analysis to assess net benefit.

Conclusion

Our model effectively predicts in-hospital mortality in patients with GIB, indicating that it may prove to be a valuable tool in future clinical practice.

Performance of the New ABC and MAP(ASH) Scores in the Prediction of Relevant Outcomes in Upper Gastrointestinal Bleeding

Background & Aims: Several risk scores have been proposed for risk-stratification of patients with upper gastrointestinal bleeding. ABC score was found more accurate predicting mortality than AIMS65. MAP(ASH) is a simple, pre-endoscopy score with a great ability to predict intervention and mortality. The aim of this study was to compare ABC and MAP(ASH) discriminative ability for the prediction of mortality and intervention in UGIB. As a secondary aim we compared both scores with Glasgow-Blatchford score and AIMS65. Methods: Our study included patients admitted to the emergency room of Virgen de las Nieves University Hospital with UGIB (2017-2020). Information regarding clinical, biochemical tests and procedures was collected. Main outcomes were in-hospital mortality and a composite endpoint for intervention. Results: MAP(ASH) and ABC had similar AUROCs for mortality (0.79 vs. 0.80). For intervention, MAP(ASH) (AUROC = 0.75) and ABC (AUROC = 0.72) were also similar. Regarding rebleeding, AUROCs of MAP(ASH) and ABC were 0.67 and 0.61 respectively. No statistically differences were found in these outcomes. With a low threshold for MAP(ASH) ≤ 2, ABC and MAP(ASH) classified a similar proportion of patients as being at low risk of death (42% vs. 45.2%), with virtually no mortality under these thresholds. Conclusions: MAP(ASH) and ABC were similar for the prediction of relevant outcomes for UGIB, such as intervention, rebleeding and in-hospital mortality, with an accurate selection of low-risk patients. MAP(ASH) has the advantage of being easier to calculate even without the aid of electronic tools.

The effect of the shock index and scoring systems for predicting mortality among geriatric patients with upper gastrointestinal bleeding: a prospective cohort study

BACKGROUND

Gastrointestinal (GI) bleeding is an important cause of mortality and morbidity among geriatric patients.

OBJECTIVE

To investigate whether the shock index and other scoring systems are effective predictors of mortality and prognosis among geriatric patients presenting to the emergency department with complaints of upper GI bleeding.

DESIGN AND SETTING

Prospective cohort study in an emergency department in Bursa, Turkey.

METHODS

Patients over 65 years admitted to a single-center, tertiary emergency service between May 8, 2019, and April 30, 2020, and diagnosed with upper GI bleeding were analyzed. 30, 180 and 360-day mortality prediction performances of the shock index and the Rockall, Glasgow-Blatchford and AIMS-65 scores were evaluated.

RESULTS

A total of 111 patients who met the criteria were included in the study. The shock index (P < 0.001) and AIMS-65 score (P < 0.05) of the patients who died within the 30-day period were found to be significantly different, while the shock index (P < 0.001), Rockall score (P < 0.001) and AIMS-65 score (P < 0.05) of patients who died within the 180-day and 360-day periods were statistically different. In the receiver operating characteristic (ROC) analysis for predicting 360-day mortality, the area under the curve (AUC) value was found to be 0.988 (95% confidence interval, CI, 0.971-1.000; P < 0.001).

CONCLUSION

The shock index measured among geriatric patients with upper GI bleeding at admission seems to be a more effective predictor of prognosis than other scoring systems.

Validation of the new ABC score for predicting 30-day mortality in gastrointestinal bleeding

BACKGROUND/AIM

The ABC score is a new pre-endoscopic scoring system that was recently developed to accurately predict one-month mortality in upper and lower gastrointestinal bleeding (GIB). We aim to validate this new score on a cohort of Lebanese patients treated in a tertiary care center and to compare it to currently existing scores.

METHODS

Adult patients admitted to the American University of Beirut Medical Center (AUBMC) with overt GIB between January 2013 and August 2020 were included. The area under receiver operating characteristic (AUROC) curves of the ABC score in predicting 30-day mortality was calculated using the SPSS software. Other optimal existing scores for predicting mortality (the Oakland score for lower GIB, the AIMS-65 and the Rockall scores for upper GIB)s were also assessed and compared to the ABC score.

RESULTS

A total of 310 patients were included in our study. For upper GIB, the ABC score showed good performance in predicting 30-day mortality (AUROC: 0.79), outperforming both the AIMS-65 score (AUROC 0.67, p < 0.001) and the Rockall score (AUROC: 0.62, p < 0.001). For lower GIB, the ABC score also had good performance which was comparable to the Oakland score (AUROC: 0.70 vs 0.56, p = 0.26).

CONCLUSION

In our cohort of patients, the ABC score demonstrated good performance in predicting 30-day mortality for patients with upper and lower GIB compared to other established risk scores, which may help guide management decisions. This simple and novel score provides valuable prognostic information for patients presenting with GIB and appears to be reproducible in different patient populations.

Shock index as a predictor for short-term mortality in helicopter emergency medical services: A registry study

BACKGROUND

The value of shock-index has been demonstrated in hospital triage, but few studies have evaluated its prehospital use. The aim of our study was to evaluate the association between shock-index in prehospital critical care and short-term mortality.

METHODS

We analyzed data from the national helicopter emergency medical services database and the Population Register Centre. The shock-index was calculated from the patients' first measured parameters. The primary outcome measure was 1- and 30-day mortality.

RESULTS

A total of 22 433 patients were included. The 1-day mortality was 7.5% and 30-day mortality was 16%. The median shock-index was 0.68 (0.55/0.84) for survivors and 0.67 (0.49/0.93) for non-survivors (P = .316) at 30-days. Association between shock-index and mortality followed a U-shaped curve in trauma (shock-index < 0.5: odds ratio 2.5 [95% confidence interval 1.8-3.4], shock-index > 1.3: odds ratio 4.4 [2.7-7.2] at 30 days). Patients with neurological emergencies with a low shock-index had an increased risk of mortality (shock-index < 0.5: odds ratio 1.8 [1.5-2.3]) whereas patients treated after successful resuscitation from out-of-hospital cardiac arrest, a higher shock-index was associated with higher mortality (shock-index > 1.3: odds ratio 3.5 [2.3-5.4). The association was similar for all ages, but older patients had higher mortality in each shock-index category.

CONCLUSION

The shock-index is associated with short time mortality in most critical patient categories in the prehospital setting. However, the marked overlap of shock-index in survivors and non-survivors in all patient categories limits its predictive value.

Use of age shock index in determining severity of illness in patients presenting to the emergency department with gastrointestinal bleeding

OBJECTIVES

This study aimed to make a comparison between classical shock index (SI), modified shock index (MSI), and age shock index (age SI) for predicting critical patients presenting to the emergency department (ED) with gastrointestinal bleeding (GIS).

METHODS

The study, which was planned retrospectively, consisted of patients diagnosed with GIS bleeding at the ED admission. Triage time vital signs were used to calculate SI, MSI, and age SI. These results were compared with intensive care admission, endoscopic/colonoscopic (E/C) intervention, blood transfusion, and mortality criteria, which we define as adverse outcomes.

RESULTS

The study included 151 patients. Seventy-nine (52.32%) of the patients had at least one adverse outcome. Of the 151 patients, 19 (12.58%) had ICU admission, 27 (17.88%) underwent endoscopic/colonoscopic (E/C) intervention, 68 (45.03%) received a blood transfusion, and 6 (3.97%) died. There was a significant difference between patients who had no adverse outcome and those who had at least one adverse outcome in terms of SI, age SI, and MSI. We performed ROC curve analyses to evaluate the diagnostic performances of all indices for predicting adverse outcomes. AUC (area under the curve) values for age SI was the highest (age SI AUC = 0.711, p < 0.001; SI AUC = 0.616; MSI AUC = 0.617). The performance of the age SI was significantly higher than the SI (p = 0.013) and the MSI (p = 0.024) for predicting adverse outcomes. The cut-off value for the age shock index was 45.12.

CONCLUSIONS

In patients with GIS bleeding, age SI, which can be easily calculated in triage, is more significant than SI and MSI for predicting the critical patient.

The Clinical Value of Multislice Spiral Computed Tomography in the Diagnosis of Upper Digestive Tract Diseases

Imaging methods for gastrointestinal diseases were based on X-ray imaging until the 1970s, but the development of fiberoptic endoscopy in the 1980s has replaced X-ray imaging. Endoscopy can directly observe the location, size, scope, and color of lesions and obtain pathological results through biopsy, while ligation and other treatments can be performed on polyps and other lesions. Studies have shown that multilayer spiral computed tomography (CT) examination after standardized gastrointestinal preparation and full use of the advantages of various 3D postprocessing reconstruction techniques are of great clinical value in the detection of gastrointestinal diseases, determination of the nature of lesions, localization of lesions, and staging of gastrointestinal malignancies and can make up for the shortcomings of fiberoptic endoscopy, and various 3D postprocessing reconstruction modes have their own advantages and disadvantages. Among them, conventional CT cross-sectional images are the basic images for the diagnosis of various gastric testicular lesions. Axial images, especially thin-layer axial images, can detect the absolute majority of lesions, but there are limitations in observing the anatomical position of lesions, invasion of surrounding tissues, lymph node metastasis, vascularity, and determination of the stage of malignant tumors.

Letter: the Shock Index and predicting outcomes in patients with upper gastrointestinal bleeding. Author's reply

LINKED CONTENT

This article is linked to Saffouri et al and McPherson and Hammond papers. To view these articles, visit https://doi.org/10.1111/apt.15541 and https://doi.org/10.1111/apt.15605.